Yesterday, the U.S. Department of Health and Human Services (HHS) and U.S. Department of Justice (DOJ) issued a letter to American hospitals and interest groups regarding providers’ use of electronic medical records (EMR) for fraud and abuse.

The letter outlined “troubling indications” that some providers are using EMR technology to “game the system,” including the following fraud and abuse concerns:

• False documentation;
• Cloning of medical records in order to inflate provider payments (and risk medical errors); and
• Use of EMR to facilitate upcoding on intensity of care or severity of patient conditions.

The letter emphasizes that patient care information must be verified individually to ensure accuracy, and cannot be cut and pasted from a different record of the patient.  The DOJ and HHS warned that the Centers for Medicare and Medicaid Services (CMS) is specifically reviewing billing through audits and initiating more extensive medical reviews to ensure proper coding of evaluation and management services.  The letter also notes that CMS will review comparative billing reports to identify outlier facilities and will consider future payment reductions as warranted.

The American Hospital Association (AHA) President issued a letter in response to the DOJ and HHS, noting that while cloning and upcoding should not be tolerated, “more accurate billing and coding does not necessarily equate with fraud.”  The AHA President noted the complexities in Medicare and Medicaid billing and reiterated the AHA’s repeated requests for national guidance on how hospitals should report emergency department and clinic visits. The letter also noted the AHA’s willingness to work with CMS to develop and vet such guidelines.